Deborah Howell (Host): Surgery is kind of a big deal, both before and afterward. And there's so many questions about anesthesia and nausea. Gara Knudtson, Doctor of Nurse Anesthesia Practice and certified registered nurse anesthetist with Pullman Anesthesia at Pullman Regional Hospital is with us today. She'll explain why some patients experience nausea and vomiting after a surgical procedure, what CRNAs can do to help reduce the likelihood of postoperative nausea and vomiting, and how long anesthesia stays in the body. Welcome, Gara.

Gara Knudtson, DNAP, CRNA: Hi, thanks so much for having me.

Host: Oh, it's so good that you help people through this because, you know, surgery is traumatic enough, and then you don't feel great afterwards, so I'm really glad we're doing this show. Is it all right if we jump right in?

Gara Knudtson, DNAP, CRNA: Yeah. Let's do it.

Host: Okay. So, why does anesthesia make some patients nauseous after surgery?

Gara Knudtson, DNAP, CRNA: So, nausea, vomiting are some of the most common side effects to medications. And most notably are narcotics. And our anesthetic gases that we use are our main offenders. So especially patients undergoing general anesthesia, who tend to receive those inhalation agents as well as narcotic anesthesia, are just more prone to postoperative nausea and vomiting.

Host: Are any groups more likely than others to experience postoperative nausea and vomiting or PONV?

Gara Knudtson, DNAP, CRNA: Yes. So, patients with a history of motion sickness; non-smokers, which, side note, this is not me advocating for people to smoke or to continue smoking by any means; patients undergoing laparoscopic surgeries, gynecological procedures, and especially laparoscopic gynecological procedures. And we tend to see younger patients, younger than middle age, tend to be more prone to postop nausea and vomiting as opposed to our more elderly population.

Host: Interesting. Finally, score one for the elderly population, right?

Gara Knudtson, DNAP, CRNA: Right.

Host: So, can anything be done prior to surgery to decrease the chance of experiencing postoperative nausea and vomiting?

Gara Knudtson, DNAP, CRNA: Absolutely. First of all, make sure you tell your nurse anesthetist the morning of surgery that if you've experienced postoperative nausea and vomiting in the past, or if you have a history of motion sickness. Typically, especially if you've had surgery before, we tend to be able to see that in your health history. But it's always good to just have a conversation in the preop area to make sure everyone's on the same page.

In addition to that, we use a variety of techniques to help limit, if not, hopefully completely eliminate the experience of postoperative nausea and vomiting with a variety of anti-nausea medications and altering our anesthetic technique.

So, one of the main things we do is called a TIVA or a total IV anesthetic. And what that does is allow us to completely eliminate our inhalation agent, which is our main hitter when it comes to causing postoperative nausea and vomiting. So, we get people off to sleep with medicine in their IV, and then we use that same medicine, propofol, to keep them sleepy for the remainder of their surgery.

Host: Got it. Now, of course, I think a lot of people are wondering like I am, would you ever use a patch or a wristband like you do when you go on a boat?

Gara Knudtson, DNAP, CRNA: Absolutely. Scopolamine patches work great for a lot of people. They do come with some side effects that include dry mouth or some blurred vision. So, not everyone loves those side effects. Not everyone experiences those side effects though. If you're interested in using a scopolamine patch or if you've had success with a scopolamine patch in the past, definitely let us know. We're happy to order those. And those are great because they can stay on for three days. So, that extended postoperative period, you get a little extra anti-nausea treatment.

Host: That's great. Okay. And now if you've experienced postoperative nausea in the past, will you always experience it when receiving anesthesia?

Gara Knudtson, DNAP, CRNA: So, not necessarily. It's very dependent on the type of anesthesia you're getting, the type of surgery you're having, especially if we know that you have a history of postoperative nausea and vomiting. We use a variety of different techniques and try to alter what was done in the past to make sure your recovery with this current surgery is better. So like I've kind of mentioned, TIVAs are one of the main things we do. We also utilize a wide range of regional anesthetic techniques to help limit, if not completely eliminate, the need for narcotic medications, which then eliminates all the side effects that come along with those narcotics.

Host: Yeah. The big 100,000-dollar question, I think, how long does anesthesia stay in your system?

Gara Knudtson, DNAP, CRNA: It really depends on the drugs that we use, medications that we use for your anesthetic, as well as the duration of your procedure, so how long you've received those medications. Some medications stay in your system for 10 to 15 minutes, while others may stay in your system for a couple hours, depending on the length of the surgery. Most people who experience postoperative nausea and vomiting following an anesthetic have it resolved within a couple hours due to the medications we use to treat postoperative nausea and vomiting. And we have some rescue medications that tend to work great in the recovery room if, despite our best efforts, people are still nauseous postoperatively.

Host: So, people that say, you know, I had surgery a week ago and I'm still feeling hung over from it. Is that a figment of their imagination?

Gara Knudtson, DNAP, CRNA: So, I would say a week is probably a little bit of an exaggeration. However, we do see, depending on the medications we use and the patient. So, most notably, elderly patients, patients that have kidney or liver dysfunction or chronic kidney or chronic liver disease tend to hold on to those medications. They're not able to metabolize them as quickly as what kind of your normal healthy standard patient does. So, they very well keep those medications and some of those side effects on board for a few days, if not close to a week.

Host: Sounds good. We're getting to the end of our time, and I'm just wondering if there's anything you'd like to add to kind of ease people's minds.

Gara Knudtson, DNAP, CRNA: I know that there is a fair amount of anxiety that comes along with having surgery, especially if you've had a bad outcome in the past, as far as pain or postoperative nausea and vomiting goes. And I've had countless patients tell me that they would rather have pain postoperatively than be nauseous.

I just want to reiterate, make sure you let your nurse anesthetist know, day of surgery, that you've had a bad experience in the past with nausea, and we will do everything we can to make sure you wake up comfortably. Sometimes, despite our best efforts, people are still nauseous. But the medications we use these days are a lot cleaner, I don't know that that's the best way to describe it, but they tend to have fewer side effects and be metabolized quicker than some of the anesthetic medications that were used 10, 20, 30 years ago, and we have some great rescue medications available. So, just know that we will take excellent care of you.

Host: That is really good to hear. And my final question is people who've had multiple surgeries over the course of a lifetime, do they have any lingering effects from anesthesia?

Gara Knudtson, DNAP, CRNA: That's an interesting question, and it's really hard to study that, because those are studies that have to take place over a multiple, multiple years. There have been some correlations with young children that have multiple surgeries early in life, and the potential for them to have some cognitive impacts, or impacts to their cognition as they grow and age. And we also see with our elderly population, specifically patients that have dementia or Alzheimer's, who have surgeries later in life, who have surgeries that last longer in duration tend to have more of an impact to their cognition postoperatively. And it's not uncommon to see a decline in their cognition for up to a couple weeks postoperatively, and some patients regain what they had and get back to baseline, not everyone does.

One of the benefits to using a TIVA or a total IV anesthetic is that we can limit the impact on patient's cognition, specifically patients with Alzheimer's or dementia, because like I said, our inhalation agents really are just a big hitter when it comes to impacting cognition postoperatively and our postop nausea and vomiting patients. So, TIVAs are great. And, in those specific populations, that tends to be our anesthetic of choice.

Host: Sounds good. I'm glad the medicine is "cleaner" than it used to be and that people are getting care from wonderful, wonderful CRNAs such as yourself. Gara, thank you so much for being with us today to enlighten us. It was really informative.

Gara Knudtson, DNAP, CRNA: Thank you so much for having me.

Host: And to learn more about Pullman Anesthesia or to schedule a consult, please visit pullmanregional.org/anesthesia. This has been The Health Podcast from Pullman Regional. I'm your host, Deborah Howell. Thanks for listening and have yourself a terrific day.